LifeWise Student Enrollment Permission Form

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Ask for gender?

Ask for Classroom Teacher?

Allow option to add additional parent information?

Ask T-Shirt Question?

Ask for Additional Email Address?

Ask Student Needs Question?

Yes/No Question 1?

Yes/No Question 2?

Yes/No Question 3?

Yes/No Question 4?

Yes/No Question 5?

Text Response Question 1?

Text Response Question 2?

Text Response Question 3?

LifeWise Program Name

Students excused from school for this purpose must first attend at least the minimum instructional minutes set by the State before leaving campus for moral and religious instruction. The minimum instructional day for students in grade 3 is 230 minutes (Education Code section 46112). The minimum instructional day for students in grades 4-6 is 240 minutes (Education Code section 46113). No student shall be excused from school for this purpose on more than four days per school month (Education Code section 46014). Students are responsible for any missed schoolwork.

I authorize the principal or designee to release my child, the student named on this form, to a LifeWise staff member to participate in moral and religious instruction. I understand and agree that my child’s School District is not responsible for and does not assume liability for my child’s participation in this activity. I also agree to waive any and all claims against the school district, city in which it is located, and the Board of Education and/or its officers, agents or employees arising from, or relating to, my child’s release from school and participation in moral and religious instruction.

Language

Please select your language.

Student Information

Student First Name

Student Last Name

Birth Date

Date must be in MM/DD/YYYY format

Gender

School Year

School

Grade

Classroom Teacher

Shirt size

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Street Address

City

State

Zip Code

Are there any custody arrangements or no contact orders we should be aware of?

Please explain the custody arrangements for this Student.

Add another parent/guardian

Additional Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to student (if not custodial parent/legal guardian)

Phone

Do you have the same address as the parent/guardian above?

Street Address

City

State

Zip Code

Additional Information

Additional (parent/guardian) email address for classroom communications

Does your student have any learning, behavioral or emotional needs of which we should be aware?

Please explain your student's needs:

Does your student have any medical conditions we should be aware of?

Describe Diagnosed Medical Conditions

Signs and Symptoms of Medical Emergency (list specific symptoms to watch for)

Emergency Action Steps (When symptoms escalate - Include steps like administering medication, the student self-administering, calling 911, contacting parents, etc. )

A member of the Program team will reach out to you to review and confirm these important details.

Does your student have any allergies we should be aware of?

Allergens (Food, medications, bee stings, etc.)

Typical Reaction

Emergency Treatment Instructions (e.g., antihistamine, epinephrine (Epi-Pen), call 911)

Does your student need emergency medication on site at LifeWise?

Do you consent to the photography or video of your student while in LifeWise, for promotional purposes?

Do you consent to the disclosure of personally identifiable information (as defined in FERPA) including medical information to LifeWise personnel in the event of a medical emergency or for reasons determined by the school district as appropriate.

Do you consent to the disclosure of personally identifiable information (as defined in FERPA) including medical information to LifeWise personnel in the event of a medical emergency?

Do you agree with the above statement?

Type your answer here

Yes, I choose to allow my student to attend LifeWise Academy classes.

I understand that this form will not be processed until I verify my email address in the next step.

Yes, I am the custodial parent or legal guardian of the minor student named above. I have the legal right to and am signing this permission form on behalf of myself and the child’s other parent or legal guardian.

Yes, I have read, understand and agree to the terms and conditions of the Release of Liability and Assumption of Risk found at lifewise.org/floridarelease. I understand that by signing this form, I am voluntarily giving up substantial legal rights on behalf of myself, my child, and others.

Yes, I have read, understand and agree to the terms and conditions of the Release of Liability and Assumption of Risk found at lifewise.org/californiarelease. I understand that by signing this form, I am voluntarily giving up substantial legal rights on behalf of myself, my child, and others.

Signature

Print Name of person completing this form:

Signature

Do you accept this signature as your own?

Yes

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This program is not sponsored by the local school district. Student participation is voluntary upon written permission of the parent/guardian. This permission form will remain in effect as long as the child is enrolled with the local public school.

This program is not sponsored or endorsed by the local school district. Student participation is voluntary upon written permission of the parent/guardian. This permission form will remain in effect as long as the child is enrolled with the local public school.

Policies are available at lifewise.org/parentinfo.

The school district and its employees shall not incur any liability as a result of any injury sustained by the student related to participation in the LifeWise program.

LifeWise Program ID

Director Email

School Year One Option

Program State